1. According to a new practice guideline from the American College of Physicians, non-pharmacological therapies for urinary incontinence (UI) in women, such as pelvic floor muscle training and bladder training, were effective at treating UI and had few side effects.
2. Pharmacologic therapies were moderately effective at treating urgency UI, and are recommended if non-pharmacologic treatments fail.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Urinary incontinence (UI) in woman is associated with substantial morbidity. Unfortunately, UI is often unrecognized and undertreated. In this practice guideline, the American College of Physicians (ACP) collates the results from a literature review of different non-surgical UI treatments. Specifically, they describe the effectiveness of drug-based therapies and non-drug based therapies such as pelvic floor muscle training (PFMT). The ACP found that non-surgical therapies are effective at treating UI. In particular, they recommend PFMT for treatment of stress UI. Similarly, they recommend bladder training, a behavioral therapy to extend the time between urinating, in women with urgency UI. For mixed UI, the ACP recommends both PFMT and bladder training. The organization recommends treatment with medications in women with urgency UI only after bladder training has failed. The guidelines further discourage the use of medications for treatment of stress UI. Finally, the ACP endorses weight loss and exercise to control UI symptoms in women with obesity. Of note, many studies underlying these guidelines did not specify whether patients had received prior UI treatment, which limits the certainty of the recommendations. Furthermore, although authors state that these guidelines are targeted towards all physicians, the guidelines focus only on therapies available to primary care providers and do not assess non-surgical therapies that are typically performed by specialists.
In-Depth [meta-analysis]: This 2014 ACP guideline is based on a review and meta-analysis of UI literature published between 1990 and 2013. To derive the guidelines, the authors summarized data on continence, improvement in UI symptoms, quality of life, and adverse effects of therapy. The ACP evaluated several non-pharmacologic treatments, including PFMT, PFMT with biofeedback using vaginal electromyography, bladder training, care from a specialized continence team, and weight loss and exercise in women with obesity. Pharmacologic therapies included antimuscarnics, β3-adrenergic agonists, duloxetine and estrogen. Unfortunately, there was not sufficient evidence to compare non-pharmacologic with pharmacologic therapy. The ACP’s analysis found that the pharmacologic interventions investigated were equally effective compared to each other, but side effects, and subsequent therapy discontinuation, varied between medications. They therefore recommend that pharmacologic therapy be guided by tolerability of individual drugs. The ACP recommends non-pharmacologic therapy as first-line treatment for UI because of its superior side-effect profile compared to pharmacologic interventions.
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